Air Force in High-Stakes Debate Over HIV-Prevention Drug for Pilots

Truvada, an antiretroviral drug, can significantly reduce the risk of contracting HIV. Officially, the U.S. Air Force doesn't allow its pilots to take it because of safety concerns. However, the drug's use has been approved by the Centers for Disease Control and Prevention. (Justin Sullivan/Getty Images)
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Military.com10 Jun 2018By Oriana Pawlyk

If the policy were different, Lt. Jones might be transferring to the U.S. Air Force now, knowing the service is short on pilots.

But Jones, who has served in the Navy since 2010, will extend his career there instead of joining the Air Force Reserve. The reason? The Air Force does not allow its pilots to take a popular medication designed to prevent HIV infection. The Navy does.

Critics say the Air Force's policy represents an overly conservative approach that borders on homophobia, since the medication is commonly used by gay, sexually active individuals. Meanwhile, Air Force leaders say they need time to rewrite older policies.

While airmen who have been denied a prescription see the move as the Air Force indicting them under the assumption they are living a promiscuous lifestyle not in keeping with service values, Air Force officials say current policy is based on safety concerns.

Jones, an E-2 Hawkeye pilot who asked that his first name not be published for privacy reasons, doesn't have human immunodeficiency virus, but the pill -- commonly known as Truvada and used as a pre-exposure prophylaxis treatment (PrEP) to reduce the risk of HIV -- is banned in the Air Force for those who fly.

For Jones and others who spoke with Military.com, it's become a choice between maintaining a safe and healthy lifestyle and fearing the worst; choosing between their well-being and their careers. It's an impossible choice for many, and these service members hope they will not be forced to make it for long.

The Air Force may make a decision for its rated community to use PrEP this fall, officials recently told Military.com.

In the meantime, the stakes remain high. One pilot said his career was brought to an end over his use of PrEP. Others say they were shamed or subjected to intrusive questions by health care providers over their pursuit of the drug.

"I've weighed my options," said Jones. "In the Navy, my prescription is already taken care of and I have that established. If I go Air Force ... I'm not willing to put my safety or my health at risk if they're ignorant to something that's actually really beneficial for a lot of people."

The Battle

Pilots say the service is long overdue on a decision to overturn its policy regarding Truvada and trails behind other services. In the last three years, the Navy has begun to allow its aircrew to stay on a pill regime and maintain current flight status. The Army now evaluates its aviators on a case-by-case basis for the medication.

The Air Force requires a waiver for pilots to use the medication. But to date, said Col. John Oh, chief of wounded warrior medical policy and operations, no Air Force waivers have gone out to the rated community since Truvada was approved for HIV PrEP by the Food and Drug Administration in 2012.

Waivers for PrEP are not required for airmen who are in a non-flying status, said Oh, who previously served as chief of preventive medicine for the Air Force Medical Support Agency at Defense Health Headquarters.

Airmen on a flying status, however, must have the aeromedical waiver in place to take Truvada as it is not on the approved list of medications, Oh told Military.com in a June 4 interview.

Meanwhile, the drug's use has been sanctioned by the Centers for Disease Control and Prevention. The Federal Aviation Administration OKs it on a case-by-case basis.

In December, Jones tried to pursue a waiver via his Navy flight doctor and then through an Air Force physician before it got too complicated, he said.

In the Navy, "it's really easy," Jones said.

Regarding the Air Force process, "why would I want to do that to myself?" he said.

Airmen who spoke to Military.com said they are frustrated with the lack of clarity on the current policy, knowing that some of their friends are on the drug because their Air Force flight doctors turn a blind eye to its use, while they -- working through proper waiver channel authority -- have been denied.

The airmen Military.com spoke with have acquired the drug through civilian physicians, or from military doctors while on a joint assignment with a sister service. Some have Air Force flight doctors who've signed off, knowing their patient has already been on Truvada for years without showing negative effects.

These officers still use Tricare, the Defense Department's health care program, to obtain their prescription regardless of who their original physician was. Some had a co-pay as little as $25. Others had no co-pay at all.

The airmen said they believe the Air Force is the least forward-thinking service when it comes to the medical needs of men who have sex with men, or MSM. And they worry it makes the service less attractive to gay men who may want to serve.

"HIV prevention is really a readiness issue," Oh said, agreeing with their concerns.

"Every year, there's still several hundred service members who come down with HIV infection, including airmen," he said. "These are trained assets; these are folks we have invested in."

In the Air Force alone, 40 to 50 airmen are diagnosed with HIV each year, Oh said.

Service officials, including Chief of Staff Gen. David Goldfein, have said the Air Force invests between $3 million and $12 million into each pilot over the course of his or her career.

Oh said that if airmen develop HIV, it has a clear, adverse effect on operational readiness.

HIV-positive personnel in the Air Force must undergo medical evaluation for the purpose of determining status for continued military service. While the Air Force may not kick an airman out for this reason, often the airman becomes non-deployable.

And pilots say if they are forced to choose between protecting their health or their careers, that too affects readiness.

"If you lose just one fighter pilot, you can't tell me that if a congressman or congresswoman doesn't get told that [millions of dollars] was simply wasted, that they wouldn't care at the congressional level. I would bet money that they would," said an Air Force major who is a special operations pilot as well as a combat systems officer.

The major, who asked not to be identified for fear of reprisal, is currently stationed overseas and has been flying for eight years.

The special operations pilot has been on Truvada since 2015. He received his most recent aeromedical check-up three weeks ago. His Air Force doctor signed off without batting an eye, he said.

"Nobody has taken me off of flight status. Or they're just really bad at their jobs and haven't noticed," he said.

After 12 years in the Air Force, the major doesn't believe the service will ever sanction a sweeping policy move.

"This is a combination of issues," he said. "There's probably lots of people who want to be on it but have been told [they] can't be, and so then they don't ask for a waiver ... or they're told the waiver is not going to go anywhere, so then they get denied anyways."

The Air Force's apparent lack of interest in making a policy change on Truvada a priority may be a result of this pattern, the major said.

"I know people who are on it who don't say that they are [for these reasons]," he said.

A Potential Career Killer

A former colonel and fighter pilot who worked on the Joint Staff at the Pentagon went above and beyond to get approval, meeting multiple times with his flight doctor and other physicians and psychologists, and submitting to tests at Walter Reed National Military Medical Center.

In 2015, he was approved to take Truvada.

"This happened with Air Force approval and sanction," the former colonel said, adding approval likely was given because he wasn't flying while in the staff job. He asked not to be identified for current career concerns.

As his time with Joint Staff came to an end, he began the transition process back into a flight job. He asked to sign up via the Air Force's waiver system to extend his medication and was denied.

He appealed for an exception to policy, which came back from the Air Force Surgeon General's office saying it needed to be approved by his four-star chain of command. That meant he needed the sign-off of Vice Chairman of the Joint Chiefs of Staff Gen. Paul Selva.

"Do I really have to do this?" the colonel said. "He's busy solving world peace."

Instead, he quietly went to a civilian provider and paid roughly $1,000 out of pocket for the drug.

Despite his efforts, the Air Force found out. He thinks because he provided his Social Security number to the pharmacy to receive a small discount, Tricare flagged it.

He found out that during his waiver request, the doctor handling the case told his new flight doc that perhaps the colonel should not be on flying status because he was at "higher risk for HIV."

"In other words, I shouldn't be on flying status because I'm gay," he said.

Despite that, he made it to his next base to take another high-level position in 2017. Two months later, his flight status was re-evaluated and denied because of his ongoing PrEP use.

"The options presented to me were to retire, or to take another staff job," he said.

He retired with 21 years in service.

A Lack of Knowledge

Among 769 service members prescribed PrEP between 2014 and 2016, 87 percent were identified as men who have sex with men, according to a CDC study authored by Dr. Jason Okulicz, an infectious disease specialist at Lackland Air Force Base, Texas.

But in a survey of health care providers, 49 percent rated their knowledge of PrEP as poor, and only 29 percent reported ever having prescribed PrEP to their patients.

Lack of knowledge on the issues has one lieutenant colonel in the Air National Guard concerned for future airmen, including enlisted personnel who may be loadmasters or boom operators who go up with pilots in their everyday duties.

"These guys may not have the rank to push the issue," said the lieutenant colonel, a C-17 pilot.

While some airmen have found help from medical professionals, others run into doctors who lecture them on their lifestyle.

Such was the case for Capt. Brandon Bierlein, a JAG counsel at Dyess Air Force Base, Texas, who was commissioned in 2013.

During a joint assignment with the Army in Africa, he talked to a Navy doctor, who gave him a prescription. In 2015, he started taking Truvada regularly. And while Bierlein never needed a waiver, he received pushback.

To continue his prescription post-deployment, he had to convince his Air Force doctor he wasn't out to participate in a hook-up culture that the service frowns upon.

"You need to be very, very careful about what you say. You just need to represent the right amount" of sexual activity, he said, adding that, in his experience, claiming eight to 12 partners in a given year is the right answer.

"If you say too much, it frankly turns into a different conversation. One doctor once told me, 'The best course of action is for you to meet someone, settle down and start a family,' " Bierlein said.

He was in a monogamous relationship at the time and never expected to have to skew the truth to his physician in order to safeguard his health, he said.

The special operations major said he has had similar experiences.

"Some of the questions you get are very personal, like, 'What are the high-risk activities that you engage in?' " the major said.

He said he has received questions about his husband: Is he on PrEP and, if so, why? How do they interact with each other? Do they share a bedroom?

To him, the questioning implied their relationship was not sound or they engaged in a swinger lifestyle, he said.

"That's none of their f---ing business," the major said, comparing it to women receiving hostile treatment when asking to be put on birth control.

"What? Are you going to call her a slut if she wants to be on birth control? No, you're not," he said. "You don't tell a married couple they can't have birth control."

The Science

In August, the Air Force will begin reviewing a number of medications that pertain to aerospace medicine, said Okulicz, the infectious disease specialist at Lackland.

"We're not performing a clinical study; we're actually reviewing the material and the Air Force has to decide. It's an evaluation of evidence and how this fits in with the Air Force's needs," he said.

According to the CDC, daily PrEP use can "lower the risk of getting HIV from sex by more than 90 percent and from injection drug use by more than 70 percent."

Taking a pill once a day builds up a concentration of the drug in the body, which protects the user against HIV infection.

Oh does not condone the use of PrEP outside official Air Force channels for fliers. "We have standards for a reason," he said.

PrEP's common side effects include headache, dizziness, abdominal pain, weight loss and change in mood. The pilots Military.com spoke with said they have never experienced negative effects or any symptoms whatsoever.

The service has a running list of medications that have been approved by aeromedical authorities, including those that require a waiver and the dosages aircrew are allowed. Physicians normally ask the crew member not to fly for two weeks to a month when starting a new medication to see how the individual responds.

Airmen who take Truvada outside of regulations say their doctors usually ask to run blood tests a few weeks after starting.

Physicians who know their patients are on Truvada will review sexually transmitted disease and sexually transmitted infection testing every three months, along with creatinine levels, which measure molecular waste generated from muscle metabolism, as well as liver and kidney function.

Some airmen have deployed while taking Truvada, they said, although that too is against the policy. Some have come off of it before deployment to avoid raising medical red flags.

Approval of HIV PrEP in aircrew is predicated on evidence that the medication is safe and effective for the patient, and will not jeopardize mission completion or flying safety, Oh said.

"Truvada compares pretty favorably compared with other medications" aircrew would be approved to take from the Air Force Medical Service's perspective, Oh added.

Right now, the approval chain usually works its way through to the major command, Guard or Reserve level depending on the airman's condition. Sometimes, it involves the Aeromedical Consultation Service at Wright-Patterson Air Force Base, Ohio, if the airman's leadership wishes to get a second opinion.

Some airmen have gotten rejections from as high up as the surgeon general's office, part of the Air Force Medical Service. For many, it's not clear who the final decision-making authority actually is.

Camaraderie Online

These airmen have found solace in their ability to exchange information about their experiences online.

"There's a couple secret Facebook groups where we discuss these issues," the C-17 Guard pilot said.

"They started way before the repeal of 'Don't Ask, Don't Tell,' " he said of the groups, one including aircrew-only officers of about 500 people.

Another includes junior officers outside the flying community. The lieutenant colonel believes there are probably more closed groups out there.

"They've been pretty quiet, until an issue like this has come up," he said.

The groups have brought camaraderie to those who feel alone at their base, or don't know who to turn to for advice.

"It's not that people want to keep it a secret, but it allows for people to, for lack of a better term, commiserate, in a safer form," he said.

Waiting Game

Oh said the Air Force is committed to evidence-based policy, which already works on a case-by-case basis for prescription medications.

"I think it’s just a question of ... [what] the aeromedical community has to go through in terms of evaluating medications, and then kind of approving that. ... The Air Force, we just haven't completed that yet," he said.

The pilots who spoke with Military.com hope for an expedited process in the future.

The National Guard C-17 pilot hasn't heard back on his application waiver for more than a year. He's been in the service 19 years, flying for more than 12 of them.

"I have about a year and a half left anyway," the lieutenant colonel said. "Say you do decide to grant these waivers based on similar protocols used by the Navy and Marines. But what do you say to a provider who is reluctant to pursue a waiver?

"To say that we have to get a waiver, well, how do we get a waiver in the Air Force?" he said.

Oh said whatever policy changes may come, it is likely airmen will still have to use a waiver system.

"I'm confident that at the end of the day that Truvada is available for our aircrew, but I think ... we just need to have the process work its way out," Oh said.

The lieutenant colonel said the choice is obvious.

"PrEP is just one added layer of protection. I would rather live my life not being HIV-positive," he said.